Toxic Shock Syndrome After Medical Abortion

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Summary and Comment

Toxic Shock Syndrome After Medical Abortion

C. sordellii caused all four cases of toxic shock that led to an FDA alert in July 2005.

In July 2005, the FDA issued an alert regarding four reports of fatal sepsis in women following medical abortion. At that time, Clostridium sordellii had been identified as the infection-causing organism in two of the women. Now, researchers have confirmed that C. sordellii caused toxic shock syndrome in all four women.

The otherwise healthy women (age range, 18–34) underwent medical abortion at 43 to 53 days’ gestation with 200 mg of oral mifepristone followed by 800 µg of vaginal misoprostol. They presented 4 to 5 days later with nonspecific complaints including abdominal pain, vomiting, and diarrhea. Presentations were marked by tachycardia, hypotension, and marked leukocytosis; absence of fever, myonecrosis, and gas production; and rapid progression to capillary leak syndrome, refractory hypotension, and death. Autopsy revealed local infection of the uterus. Clostridial antigens were identified by immunocytochemistry, and 16s ribosomal RNA gene sequences were consistent with C. sordellii infection.

Comment: In addition to these four deaths, one fatal case of C. sordellii toxic shock after medical abortion has been reported in Canada. As human C. sordellii infections are very uncommon, those described likely were related to the abortion procedure. FDA investigation found that the mifepristone and misoprostol were not contaminated with C. sordellii. Of note, the etiologic agent was identified only at autopsy using molecular amplification.

C. sordellii toxic shock after medical abortion is rare, given that mifepristone and misoprostol have been used in about 460,000 abortions in the U.S. since the FDA approved mifepristone. Nonetheless, when women who have undergone medical abortion present with the symptoms described above, clinicians should consider the possibility of toxic shock, and immediate antibiotic treatment including anaerobic coverage may be warranted (see also Journal Watch Women's Health Aug 2 2005).

— Anna Wald, MD, MPH

Published in Journal Watch Women's Health January 24, 2006